Professional Documents
Culture Documents
of each virus is approximately 11kb in length [ 1,2]. The DENV genome encodes
three structural (C, prM, and E) and seven nonstructural (NS1, NS2B, NS3,
NS4A, NS4B, and NS5) proteins [3]. The CHIKV genome encodes three
structural (C, E1, and E2) and four nonstructural (nsP14) proteins [1].
Both viruses are arthropod-borne viruses (arboviruses) sharing a common vector:
mosquitos of the Aedesgenus, specifically A. aegypti and A. albopictus [4]. Both
viruses circulate in similar geographic regions. In nonendemic regions, travelassociated infections are an important consideration for patients with a recent
travel history who present with fever. Concurrent infection with both viruses,
transmitted from either two different mosquitos or one dually infected mosquito,
is possible [5, 6]. For DENV, transmission has also been reported to occur via
infected blood products, organ donation, and prenatal and/or perinatal vertical
transmission [7].
While DENV and CHIKV present similarly as an acute febrile illness, these two
viruses have vastly different management strategies and outcomes. The majority
of CHIKV infections are self-limiting with chronic joint disease being the most
common long-term outcome, and fatality is exceedingly rare. Nonsteroidal antiinflammatory drugs (NSAIDs) are the mainstay treatment for CHIKV, but
NSAIDs should be avoided until DENV is confidently ruled out, as NSAIDs are
contraindicated in DENV infection [8]. DENV is likewise commonly a selflimiting illness, yet this diagnosis necessitates stricter monitoring due to the
potential for more significant morbidity and mortality. Infection with one serotype
of DENV confers lifelong immunity to that particular serotype but only short-term
immunity to the other serotypes; subsequent infections with a different serotype
increase the risk of severe complications [7].
2. Epidemiology
The majority of DENV and CHIKV infections affect people residing in endemic
areas, which include most of the tropical and subtropical regions in the world.
3. Clinical Presentation
differential diagnosis for a patient with suspicious clinical symptoms who is living
in or returning from travel to an endemic area. Clinical features can serve, at best,
as a guide for favoring one virus over the other, as patients may present atypically,
either by lacking the classic signs or symptoms as mentioned above, or by
presenting in an uncharacteristic manner. Laboratory diagnostic tests are thus
essential for accurate identification of the causative virus.
4. Methods for Diagnosis
provides a larger window of detection that extends well past the viremia period;
DENV RNA may be detected in urine up to day 16, compared to day 8 for blood
specimens [28]. The ability to test urine and saliva is advantageous in patients for
whom blood samples are difficult to obtain, such as in newborns and patients with
hemorrhagic syndromes [14].
RT-PCR using primers designed for structural and nonstructural domains has been
found to be useful in the rapid diagnosis of CHIKV. The combination of RTPCR/nested PCR has proved efficient for specific detection and genotyping of
CHIKV. Loop-mediated isothermal amplification (LAMP) assays can be rapidly
carried out at a single temperature in a water bath, with visually detectable results,
and comparable sensitivities to conventional PCR [17].
Detection of viral antigens is another diagnostic methodology available for DENV
infection. Nonstructural protein 1 (NS1) antigen is a highly conserved
glycoprotein produced during the virus replication process, and a soluble form of
NS1 accumulates in high concentrations in the serum of patients with both
primary and secondary DENV infections [29, 30]. Several commercial assays,
consisting of both rapid tests and enzyme-linked immunosorbent assay (ELISA)
kits, are available for the detection of the NS1 antigen. Serum is the most common
sample type. DENV NS1 can also be detected in urine samples during the acute
phase of DENV infection, which provides an opportunity for the development of a
rapid noninvasive test [11]. Lastly, NS1 antigen may be detected in the
cerebrospinal fluid (CSF) of patients with neurological symptoms [12]. A
downfall is that these tests do not differentiate between dengue serotypes, as NS1
is highly conserved by all serotypes. Additionally, these tests are most successful
during the acute phase of illness and lose sensitivity once the period of viremia
ends. The sensitivity of NS1 has also been found to be lower in DENV secondary
infections, which is thought to be due to assay interference by anti-NS1 antibodies
which are present more frequently in secondary infections [10, 29]. An antigenbased commercial detection assay is not widely available for CHIKV, and the ones
[31].
Real-time
reverse
transcription-loop-mediated
isothermal
hour under isothermal conditions and does not require sophisticated instruments,
making this method adaptive to field diagnosis. Additionally, the use of a
turbidimeter allows for quantitative detection of viral load [32]. For RT-PCR
assays described above, the one-step process reduces the chance of contamination
and there is lack of cross-reactivity between related Flavivirus groups and DENV
[19].
4.3. Sending Out Samples
Within the United States, CHIKV testing is performed at the Centers for Disease
Control and Prevention (CDC), a limited number of select state health
departments, and one commercial laboratory. The CDCs Arbovirus Diagnostic
Laboratory at the Division of Vector-Borne Diseases (DVBD) is located in Fort
Collins, CO. Test results are normally available 4 to 14 days after specimen
receipt, but reporting times may be longer during summer months when arbovirus
activity increases. Initial serological testing is performed using IgM capture
ELISA and IgG ELISA. If the initial results are positive, further confirmatory
testing is performed which may delay the reporting of final results. All results are
sent to the appropriate state health department.
The CDC Dengue Branch, located in San Juan, Puerto Rico, provides DENV
testing free of charge to submitting physicians and state and private laboratories.
A Dengue Case Investigation Form must accompany the specimen. One
potentially problematic issue with sending samples to this laboratory is that an
international shipping license is required. Another challenge, especially for
underdeveloped countries, is specimen preservation during shipment. The CDC
recommendation is that the serum specimen is frozen immediately after separation
and sent on dry ice, or alternatively kept refrigerated and sent in cold packs.
The authors declare that there is no conflict of interests regarding the publication
of the paper.